Contemporary Psychoanalysis and Homosexuality

Ralph Roughton, MD

Homosexuality cannot be classified as an illness. Sigmund Freud (1935)

At the beginning of the 20th Century, Sigmund Freud exploded all the conventional assumptions about sexuality. His 1905 monograph, Three Essays on the Theory of Sexuality, presented radical concepts of sexual freedom. Freud declared the universality of psychic bisexuality, he emphasized the ubiquity of polymorphous sexual fantasy, and he blurred the boundary between the normal and the pathological (1905). In addition, as early as 1903, Freud quite clearly stated that homosexual persons are not sick. More than 30 years later, he still held that belief, saying that homosexuality cannot be classified as an illness (1 935). He went further, pointing out that not only homosexuality, but also heterosexuality, depends upon a restriction in the choice of a sexual object. And he wrote, "In general, to undertake to convert a fully developed homosexual into a heterosexual does not offer much more prospect of success than the reverse" (1920, p.151). And yet, Freuds insistence on the non-pathological nature of homosexuality is still far from universally accepted in the psychoanalytic world. It took the International Psychoanalytic Association three years and three separate votes before it finally adopted a simple policy of non-discrimination in the acceptance of gay men and lesbians as psychoanalysts in the organization. Soon after Freud's death, many of his followers began to reconstruct a psychoanalytic literature that increasingly portrayed homosexuals as sick, even citing Freud as their authority. There is enough ambiguity in Freud's writings so that references can be selected to support one point of view, while ignoring other contradictory ones. The problem is that Freud never wrote a definitive, clarifying treatise on homosexuality, and he considered his developmental explanations to be incomplete (1922). In articles on other topics and in case reports, he tried to find ad hoc explanations for the same-sex object choice that would fit into his theory of psychosexual development (1909, 1910, 1918, 1920, 1922). Other psychoanalysts turned Freuds attempts at conceptual consistency into categories of pathological etiology. For example, the negative oedipal variation (attraction to same-sex parent, rivalry with the opposite-sex parent) seemed to account for homosexual attraction, consistent with Freuds theory of psychosexual development (1918); but later writers reified this variation into evidence of psychopathology and spoke of the negative Oedipus complex, implying a constellation of pathological features. Note the contrast, however, in how quickly the question of pathology is invoked in homosexuality and ignored in heterosexuality. When Freud said that mens exclusive sexual interest in women is also a problem that needs to be elucidated, rather than a self-evident fact (1905), no one rushed to declare that heterosexuality is pathological. There is no simple resolution of Freuds various statements about homosexuality. He was deeply committed to two different, often contradictory, principles -- sexual freedom and biological destiny. Was sexuality the domain of individual pleasure or was it the domain of species survival? Freud, the great liberator, embraced sexual freedom and accepted that there would be variations in its expression. Freud, the evolutionary biologist, saw reproduction through heterosexual intercourse as the proper aim of all sexuality. And he made no attempt to reconcile the two. What he seems to be saying is that, for our species to survive, nature requires that we reproduce. Any deviation or detour from that pathway cannot be called normal in the technical sense of fulfilling one's role in nature. B ut Freud did not consider an individual's alternate expression of sexuality to be a disorder nor did he associate it with other abnormal functioning (1905). In fact, as Lichtenstein pointed out in 1961, the great contribution in Freud's 1905 essay was the idea that sexuality is not essentially linked to procreation.

Nevertheless, later writers insisted that the only normal sexuality was heterosexuality. All development was determined by vicissitudes of the libidinal drive, progressing along a single line through psychosexual stages, successfully navigating the oedipus complex, subsuming all sexual urges under the primacy of genitality, and culminating in normal, non-incestual heterosexuality. Psychological development also progressed along this single developmental pathway and could be blocked by any interference with libidinal development. In that developmental scheme, there was no way, conceptually, to reach emotional maturity without having achieved genital heterosexuality. Genitality actually described a level of psychological maturity, but it was incorrectly equated with having resolved the oedipal conflict and made a heterosexual object choice. There was no concept of homosexual genitality, therefore no mature homosexual people. It must be acknowledged that this is a flaw in his developmental scheme that Freud did nothing to clarify. Other writers emphasized preoedipal conflicts and failure to advance beyond narcissistic object choices. Despite different theoretical language, the underlying assumption was the same: homosexuality represented developmental failure and was associated with primitive psychopathology, impaired ego functions, narcissism, and disturbed object relations. The concept was crystallized in the term arrested development. Following Freuds death, generations of psychoanalysts accepted this without question, despite contradictory evidence in everyday observations and despite Freuds having warned against such a position in 1903 when he wrote: Would that not oblige us to characterize as sick many great thinkers and scholars of all times . . . whom we gretly admire precisely because of their mental health? And he repeated, Homosexual persons are not sick. In 1963, Anna Freud published her concept of multiple lines of development. Although homosexuality was not the focus of this new concept of development, it did allow for the assessment of sexual development and emotional development along separate lines. This gave a theoretical basis for the possibility that a person could be both homosexual and psychologically mature, even though the homosexuality itself was still considered abnormal. A growing number of theorists, however, ignored this possibility and continued to advance their theories of conjoined pathology in both psychological function and sexual life. And they supported their beliefs by reporting case material from disturbed patients. What they failed to recognize is that reporting case material from homosexual patients who had serious emotional problems proved nothing -- except that it is possible to be both homosexual and psychologically disturbed, just as it is possible to be both heterosexual and psychologically disturbed. The crucial question, however, is whether it is possible to be both homosexual and psychologically mature and healthy; and, if that is true, then we should approach homosexual orientation and emotional health as independent lines of development as we do heterosexual orientation and emotional health. Ending Discrimination, Rethinking Pathology The decade of the 1990s brought a sea-change in the way homosexuality and homosexual individuals were regarded in the American Psychoanalytic Association (Asia). The new acceptance of gay and lesbian people in public life, as well as the emphasis on civil rights and justice, added to a growing realization among our members that perhaps our theories were wrong. We could no longer ignore the obvious -- that it is possible to be both homosexual and emotionally healthy -- and therefore rejecting gay men and lesbians as psychoanalytic candidates, simply because they are homosexual, is clearly discrimination. Freud was correct in 1921 when he and Otto Rank disagreed with those who said that homosexual individuals should not become psychoanalysts. They wrote, "We feel that a decision in such cases should depend upon a thorough examination of the other qualities.". In adopting Freud's position seventy years later, the APsaA concentrated first on justice. In 1991 the organization adopted a policy requiring that all evaluation decisions, from selecting psychoanalytic candidates to appointing training analysts, must be made on the basis of qualities and capacities that are relevant to functioning as a psychoanalyst, and not on the basis of sexual orientation itself. Despite bitter opposition from a small group of members, the Executive Council adopted this policy by an almost unanimous vote. A similar policy, again with strong opposition, was adopted by the Executive Council of the International Psycho-Analytical Association in 2002.

These were policy changes, decided by votes, that belatedly brought these organizations in line with contemporary thinking about homosexuality, mental health, and social justice. But they were not, as some have charged, merely ideological battles decided by political power. The new policies were backed by solid data supporting the basic premise that being homosexual is not necessarily associated with any kind of mental or emotional impairment. That question has now been answered. Here are some supporting data. The older view, that assumed pathology, had been based on accumulated anecdotes from the case study method. Although the analytic process may be unique in its access to deeper levels of the human psyche, the validity of any generalized conclusion is severely compromised by the small, unrepresentative sample and by the subjective nature of the analyst as participant-observer. Socarides (1968) and Isay (1989) reached opposite conclusions about the origins and pathology of homosexuality from their own clinical practices. Two facts about sample and subjectivity stand out: (1) Socarides based his theory on patients who also had preoedipal pathology and disturbed functioning, while Isay's typical patients were highly functioning professional men who were not dissatisfied with their sexual orientation; (2) Socarides believes that the gay rights movement is "destroying society" (1995, p. 286), while Isay has been an advocate for gay civil rights. These two clinician-theorists work with widely differing patients, and they approach them with radically different subjectivities. Thus, it is clear that we must look beyond anecdotal data from clinical practice. Regarding the origins of homosexual orientation, various biological studies have seemed promising, but thus far there is no consensus for a simple biological explanation. Recent data on twins from a large sociological study (Kendler, et al, 2000) suggest a genetic influence, in combination with experiential factors. The widely assumed causal pattern of disturbed familial relationships (too much mother, not enough father) is far from universal in homosexual men and, in fact, is also quite common in heterosexual men. The truth is that we do not know why some people are heterosexual and others are homosexual. We should not pretend that we do know. But we can say this much, with some degree of certainty, based on our present state of knowledge. Evidence points to the likelihood that the origin of sexual orientation is complex, that it involves both biological and experiential factors, and that the balance between the two may differ in different individuals. More important for a clinical perspective, however, is the viewpoint that being homosexual is neither a symptom nor an illness that requires explanation. This does not mean that gay men and lesbians are immune to sexual problems or that their sexual behavior is never shaped by psychopathology. They are prone to sexualize other needs, to form perversions, to have difficult relationships, to fear intimacy and commitment just as are heterosexual individuals, but no more so. When present, these psychological problems, not the gender of the sexual object, should be the focus of treatment. This point of view is backed by systematic comparison studies of non-patient populations, beginning with pioneering work by Evelyn Hooker (1957), in which senior clinicians, evaluating results of projective tests blindly, were unable to distinguish between homosexual subjects and matched heterosexual controls. More recent metaanalyses of large numbers of comparative studies confirm these findings; and Cohler and Galatzer-Levy conclude from their careful review that "there is little evidence of any intrinsic relation between sexual orientation and adverse mental health outcomes as determined either by personality trait measures or psychiatric evaluation" (2000, p, 311). However, they also note that individuals who grew up with substantial antihomosexual prejudice and little social support may at times have higher rates of affective disorder, suicide attempts, and substance abuse. Adolescents are particularly vulnerable to the effects of social stigma. But such reactive difficulties are not an intrinsic part of being homosexual and should carry no weight in constructing hypotheses about origins, development, and life experiences of those with a homosexual orientation. In addition, many analysts report anecdotally that they see no more psychopathology in their gay and lesbian patients than in their heterosexual patients. I have criticized the use of anecdotal case reports as data. However, it is one thing to cite a few disturbed patients as confirmation that all homosexual individuals have severe character pathology, as Socarides does, and another thing to cite a few healthy patients to disprove that generalization, as Isay and many contemporary analysts do. A few sick puppies cannot prove that all puppies are sick, but a few

healthy puppies can disprove it. The closest thing we have to a large scale illustration of the latter point is the experience over the past decade in the APsaA, where perhaps as many as one hundred openly gay men and women have been candidates (students) in our psychoanalytic institutes; many have now graduated. Of course, their personal psychoanalyses are completely private, but their work has been scrutinized in the usual ways by supervisors and teachers. Their consensus is that gay and lesbian candidates are as qualified as any other group to function in the highly specialized role of psychoanalyst, with all the necessary emotional stability, maturity, and flexibility of transference availability. Specifically, the capacity of homosexual analysts to function as opposite-sex transference objects for their patients has been evaluated favorably by Ellman (2001). In addition, several gay and lesbian faculty members have been appointed Training Analysts after going through the usual thorough evaluation. One gets quite a different picture of homosexual men and women when evaluating such highly functioning groups than one does from only seeing disturbed patients. Rethinking Theory These actions were based on fairness and justice and on more logical thinking about the use of clinical inferences. What should be done about the theories themselves? Auchincloss and Vaughan (2001) have argued that we do not need a new theory of homosexuality but rather a renewed capacity for analytic listening, one that is not preoccupied with etiology, that avoids the common assumptions of cultural bias, and that is concerned with the individual person's experience of growing up homosexual. I agree with their emphasis, but I also believe that examining the errors of our old theories will enhance our understanding of where we went wrong and how to correct our thinking. Psychoanalytic theories of homosexuality were based almost exclusively on clinical observations of a few cases, justified by the intense and deep understanding that can be derived from the psychoanalytic experience. But there are severe limitations to the validity of generalizing from anecdotal accounts because of the unrepresentative sample and because of the subjective nature of the data and its interpretation. From today's perspective, we can clearly see the faulty thinking that made it difficult for psychoanalysts to accept homosexuality as something other than pathology. Roy Schafer (1995) explains how Freud's use of binary terms (masculine/feminine, active/passive, genital/pregenital) set up implicit value hierarchies and resulted in a norm being mistaken for a fact of nature. That is, because most people make a heterosexual object attachment, it is assumed that heterosexuality, and only heterosexuality, is what nature intended. But one of the basic facts of nature is its enormous diversity and variation in design and function. Schafer finds an unwarranted leap from biological theory to moral judgment in the common assumption that "because development can proceed to reproductivity, it is only the reproductive heterosexual who is the mature, normal, healthy, fully developed person" (p. 194). Analysts observed that their heterosexual patients sexual lives improved when conflicts were resolved. They then made the mistake of assuming that the same could happen with homosexual patients -- that is, resolving conflicts would open up their freedom to enjoy heterosexual experience. It did not occur to them that the optimal outcome of analysis for homosexual patients might be less conflicted, more pleasurable homosexual lives In addition to Schafer, other prominent psychoanalysts have recently written of their changing views on homosexuality. Joyce McDougall wrote a paper early in her career (1964), presenting a small number of lesbian patients with severe character pathology which she thought, at that time, could be generalized to explain the etiology of homosexuality in women. She has recently repudiated that conclusion, stating that she had been "inexperienced and inundated with bad theory" (2001, p. 7). In 1992 Otto Kernberg discussed homosexuality as a perversion and said that it is rare to find cases of male homosexuality without significant character pathology. By 2002, he had modified that: "In contrast to perversions, homosexuality implies a sexual disposition and set of sexual activities that can be as broad, flexible, and rich as can heterosexual commitment" (p. 9). Yet he still classifies homosexuality according to underlying psychodynamics in a spectrum from severe psychopathology to health. And his criteria for health are formidable.

"If, at the end of [psychoanalysis], their homosexuality is unaffected, while they are able to function in a full and satisfactory way in all areas of their life experience, with a rich love life that integrates erotic and tender components, an object relation in depth with their sexual partner, without the manifestations of severe repression or denial of heterosexual impulses, and a capacity for a broad range of relationships in depth with both genders, the notion of homosexuality as an illness by definition would become highly questionable" (2002, p. 18). Does Kernberg judge the health of heterosexuality with comparable standards? He says that the prognosis in male homosexuals depends on their level of character pathology, the most severe category being in combination with malignant narcissism, which "presents practically the same dynamic characteristics as heterosexual malignant narcissism" (p. 20). The next logical step (as I see it) is simply consider the sexual orientation and the character structure as separate, independent factors. That is, in malignant narcissism (or in health), some individuals will be heterosexual and some will be homosexual. Michael Parsons (2000) suggests a metapsychological reformulation, from describing the source, aim, and object of the sexual drive, to thinking in terms of source, aim and quality of relatedness to the object. Freud saw the aim as primary and the object as a subservient means of satisfying the aim, but Parsons says that this is not intrinsic to the theory itself. By redefining perversion in terms of the quality of object-relatedness, Parsons keeps his focus on the unconscious and metapsychology, and suggests within this framework the possibility that a particular homosexual relationship may not be a perverse one. Despite the language of perversion in connection with homosexuality, at least he is finding a way, within his metapsychology, to think about it based on the quality of the relationship, rather than on the gender of the object. Kernberg's and Parson's conceptual shifts may seem small and inadequate steps in transforming the misguided thinking about homosexuality that has harmed generations of gay and lesbian patients and analysts. However, these are significant steps at a theoretical level, by important theorists, that complement the changes that have been brought about by the appeal to fairness and justice and by rethinking the faulty assumptions that were made about real people's lives. Rethinking Treatment Contemporary psychoanalytic thinking about treatment for gay men and lesbians begins with the assumption that we treat people, not sexual orientation. We should think of what we do as treatment for gay and lesbian individuals, not treatment of homosexuality. Not only have we moved away from focusing on changing the sexual orientation, but we also need to move the focus away from trying to find the underlying, unconscious cause of homosexuality. The implication here is that sexual orientation and mental health are independent dimensions of personality and that homosexual orientation is not in itself an indicator of any pathology. Knowing a persons sexual orientation tells us nothing about his psychological health and maturity, his character, his inner conflicts, his object relationships, or his integrity. I am not suggesting a complete lack of sexual pathology or character pathology in homosexual individuals. I am suggesting that, when they are present, we speak of a perversion or narcissism or borderline personality in a homosexual individual, just as we speak of a perversion or narcissism or borderline personality in a heterosexual individual, rather than considering such pathology to be an integral part of, and a defining characteristic of, homosexuality. Achieving heterosexual orientation is not a requirement for an analysis to be successful. Self-understanding, quality of relationships, and freedom to pursue and integrate pleasure are better measures of successful analysis than is the gender of sexual partners. An analytic process focused on uncovering the presumed pathologica l etiology of homosexuality will inevitably distort the process, and every conflict that emerges will be reduced to another aspect of the homosexual pathology. Of course we want a more comprehensive understanding of the development of sexual desire. However, I suggest that finding the origin is not of central importance in an individual clinical situation, unless one expects to change the sexual orientation. The active search will inevitably imply that being gay is unnatural and pathological, and it will confirm the patients internalized sense of shame and self -hatred. It is also a futile quest. No matter how well the early family dynamics may fit the theoretical pattern thought by some to cause homosexuality, there is no valid

study that shows a pattern of family dynamics or a history of trauma that can consistently explain why one person becomes heterosexual and another becomes homosexual. I am not suggesting that we avoid exploring the past or trying to construct a coherent narrative of the persons life only that we avoid structuring it as a quest for etiology of what may be this persons natural erotic desire. Nothing will be lost. A full and thorough analytic experience can be had without knowing why one is gay or lesbian. After all, we do very good analytic work with straight analysands without knowing what caused them to be heterosexual. For us to be good therapists for gay men and lesbians, it should be enough simply to put aside assumptions about psychopathology and to apply our ordinary analytic technique of non-judgmental listening and understanding. The difficulty with gay patients is that we do not recognize how embedded we are in heterosexual culture. In addition, most analysts are unfamiliar with many of the norms of gay life, leaving them likely to make comments that their homosexual patients experience as confirming negative attitudes toward homosexuality. For analysts who choose to work clinically with gay men, it is imperative that we become aware of our ingrained, heterosexist biases, our theoretical misconceptions, our countertransferences, and even our simple ignorance about the lives of gay people. It requires self-education and self-analysis to reduce these interferences that keep us from listening to our patients with open and unbiased attention. No special technical knowledge is needed. The ordinary method of psychoanalytic psychotherapy, if properly applied, is good enough. In recent years, the old attempt by psychoanalysts to convert patients from homosexuality to heterosexuality has resurfaced in the form of reparative therapy (Nicolosi, 1991) and in an increasing number of religious healing ministries that are set up to appeal to those seeking a cure for their homosexuality. Originally they held out great hope that homosexual attractions could be eradicated, but lately the more responsible practitioners acknowledge that they do not actually accomplish that but, instead, help people learn to control their desires and avoid acting on them. Unfortunately, much harm is often done in the process. The basic assumption is that the desires are pathological -or sinful, if it a religiously sponsored program -- and the goal is the suppression of desire and control of behavior. Often desperate and vulnerable people enter these programs, few of them are helped, and many are made to feel much worse about themselves. Two recent studies have shed some light on the basic questions of whether such programs do in fact help people change their sexual orientation and whether they cause harm to those who do not change. Dr. Robert Spitzer, a respected researcher at Columbia University, has done what is the most definitive study to date on those who feel that they have had at least some minimal change from homosexual to heterosexual orientation as the result of some form of reparative therapy (2003). His study has been sharply criticized on methodological grounds; and I agree with criticisms of his method of recruiting subjects (skewed toward those highly motivated to give positive results); the method of data collecting (a single, structured telephone interview); and relying only on subjective reports of change. Nevertheless, it is important to understand that he was trying to investigate the possibility, not the probability, of change. As a result of his study, Spitzer now believes that a small minority of highly motivated homosexuals may actually achieve some degree of change in their sexual orientation. But even he says that it is extremely rare and that it may cause harm in many others. To quote him, It may help 5,000 people, but harm 500,000 (Hausman, 2001, p. 34). Approval for a new cancer treatment with such a dismal help/harm balance would be rejected without a second thought. The other study, done by psychologists Shidlow and Schroeder (2002), studied the harmful effects in a group of 202 former patients who had failed in their attempts to change sexual orientation. They found many instances of reported psychological harm, including depression, suicidality, lowered self-esteem, and impairment in relationships. The American Psychoanalytic Association has adopted a policy stating that directed efforts to change an

individual's sexual orientation "are against fundamental principles of psychoanalytic treatment and often result in substantial psychological pain by reinforcing damaging internalized homophobic attitudes" (Minutes, 1999). Nevertheless, these controversies over treatment and homosexuality continue to erupt. In my view, can people change? is the wrong question to be foc used on. There is no doubt that some individuals, sufficiently motivated by internal shame or external pressure, are capable of managing their sexual behavior differently. Some bisexual individuals may resolve conflicts that allow a shift in the predominant object of desire. Some highly disturbed and malleable individuals, with little identity of their own, quite easily adopt a suggested role to please a therapist or to actualize a transference desire. We know that such "changes" can result from efforts directed at producing them, but data about the frequency of these "successes" can never be derived from surveys of self-selected subjects. The durability of such "changes" can only be assessed by unbiased, systematic follow-up studies. What we should be addressing in this controversy is the treatment method being used by therapists and analysts who promote reparative therapy. The problem, as I see it, is that they take the patients' request for change at face value; and, rather than exploring the source and meaning of the pain, they assume that it derives from the pathology of homosexuality. That attitude and treatment approach reinforce, rather than alleviate, the internalized homophobia, the shame, and the guilt that led these men to seek change. In contrast, an unbiased analytically oriented treatment is grounded in respect for the individual's autonomy (Drescher, 1998), operates in a spirit of collaborative curiosity and exploration, has no preconceived notion of outcome, and aims to reduce inner conflicts so that the individual then has greater freedom to make conscious choices about life goals (Roughton, 2001). It is not change that we oppose; rather, it is their coercive methods, especially the manipulation of a submissive transference, leading to reinforced shame and illusory change. I am not opposed to helping someone who wants to make conscious choices about his sexual life that differ from what I would choose, as long as we can explore the deeper levels of what it means to him. For example, I can work with a priest who chooses to remain celibate, or a married gay man with children who wants to stay married; and I can respect those as informed and freely made choices. But, in an analytic approach, the roots of the choice would be brought to consciousness and weighed within the patient's own evolving value system. It would not require that a core aspect of his being had to be labeled as a defect.

New Perspectives for the 21st Century Now I introduce a growing body of papers written by respected young analysts who have come through our educational institutes at a time when being gay or lesbian was no longer a barrier. They bring unique perspectives and insights from their own experiences of growing up, being analyzed, and learning to be psychoanalysts as homosexual individuals themselves. Their topics center on gay and lesbian experience, and they offer alternative understandings of what had previously been regarded only as pathology. Many of these papers coalesce around questions of development: Is there a normative developmental process for a boy or girl who is going to grow up to be gay or lesbian? Until very recently, people did not grow up gay. They grew up defective in secrecy, silence and shame and, too often, in danger. Can we conceptualize a normal boyhood for a gay boy? Do we dare speak of homosexual genital primacy? What is the oedipal configuration of a child with two parents of the same gender? Can we define masculinity other than as the absence of feminine traits? Can we get over the idea that gender is the only defining category in sexual relationships? Ken Corbett's series of papers (1993, 1996, 2001a, 2001b, 2001c) begins a revision of developmental concepts. As a child analyst, he works both with children and with sets of same-sex parents. His fresh insights challenge our received wisdom about development, about types and meanings of masculinity, and about growing up in a nontraditional family.

Martin Frommer (2000) argues that same sex desire is not necessarily desire for sameness. This false link led many analysts to conclude that sexual desire for someone with similar genitals can only be narcissism rather than true love (Bergeret, 2002; Roughton, 2002). Frommer challenges this view by describing a heterosexual mans identification with his girlfriend and a homosexual man's valuing of the differentness between himself and his boyfriend. He concludes, "Loving that is termed narcissistic is not about whom one loves, but how one loves" (p. 203). Scott Goldsmith (1995, 2001) rejects the notion of a negative oedipal explanation for the homosexual boy, suggesting instead that the configuration of father as love object and mother as rival is the normative experience for the homosexual boy and should be considered his positive triangulation experience. The early lack of attunement between mother and son, where she tries to evoke the expected "family romance" with her son, who instead desires a romance with his father, may instill a lifelong perception of women as intrusive and controlling. Sidney Phillips (2001) describes what it is like to grow up gay in a world that was designed for someone else. He explores the overstimulating effect on the gay teenage boy of constantly being in situations, like locker rooms, where he can neither avoid his sexual feelings nor acknowledge them. An unsuspecting heterosexist society thinks that it circumvents the problem of overstimulation by not allowing coed locker rooms; but for those attracted to their own gender, they have created just the opposite effect. Phillips discusses the adaptation the gay boy must make to this kind of overstimulation, which may lead to the massive suppression of feelings and to isolation and shame. Paul Lynch (2002) illustrates with clinical material the complicating factor in the love life of some homosexual men that results in the same splitting of tender and sexual feelings that Freud described for heterosexual men. Lynch offers a different understanding of certain behavior that analysts have assumed to be characteristic of homosexual dynamics. Dennis Shelby (2002) shines a different light on cruising, a phenomenon denigrated by psychoanalysts as compulsive searching for multiple sex partners, said to be characteristic of homosexuality. Shelby shows this to be an example of our confusing sexualization (the compulsive behavior) with sexual orientation (the homosexual orientation) and ignoring the needy self trying to make contact. Susan Vaughan (1999) tackles a rarely reported clinical experience the emergence of heterosexual fantasies in a lesbian woman. Rather than seizing this as an indicator that her patient might become heterosexual, Vaughan kept an open-minded analytic curiosity about the meaning. It soon became apparent that this was defensive heterosexual fantasy arising at a time when a deepening commitment to her female partner was threatening her sense of autonomy. Conclusions When observations do not fit theory, we should re-examine the theory, as Freud continually did. Theory loses validity when it contradicts known facts, and it is a demonstrable fact that it is possible to be both homosexual and healthy. We do not know why some individuals are heterosexual and others homosexual, but that lack should not prevent our listening to gay and lesbian patients the same way we listen to heterosexual patients. What makes it difficult to provide the same atmosphere of safety and respect are our own cultural biases, our faulty assumptions and outmoded theories, and our simple lack of knowledge and comfort with the norms of gay and lesbian lives. It is our responsibility as analysts to overcome these failings if we are to work with homosexual patients.

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