Editorials

Homosexuality and mental health services

Although intuitively one might expect such prejudice to have an adverse impacton the mental health of lesbians and gay men, this has proved hard to show.⁹ Historically, medicine and psychiatry defined homosexuality as a disease or homosexuals as disturbed. But rigorous research has failed to differentiate homosexual and heterosexual populations on the basis of personality or psychopathology.¹⁰ Ask not why homosexuals are unstable, but why they are not. Most recent research into psychological distress in homosexuals has been performed in the context of HIV and AIDS. Important though this is, it fails to address the emotional needs of the gay community in general and of lesbian women in particular. What these studies have shown, however, is that distress may be mediated by such factors as life events,¹¹ social support,¹² and self esteem.¹³ These are mainstream concepts in models describing the social origin of mood disorders. Additional evidence exists, however, that prejudice and stigmatisation amplify the effects of adverse events.¹¹

But what if professions delivering health care prove to be homophobic? In a survey of attitudes in 1989 about one third of general practitioners felt uncomfortable with male homosexuals, considered them a danger to children, and thought that they should not be employed in schools. One in nine believed that homosexuality was an illness.¹⁴ In a Canadian study in 1991, one quarter of respondents from a psychiatric faculty identified themselves as prejudiced against homosexuals.¹⁵ Last year a British survey reported that only one in two clinical medical students thought that homosexual activity could form part of an acceptable lifestyle.¹⁶ Gay men and lesbian women may commonly feel that they have dealt with a prejudiced health professional; one in four respondents to an American survey in 1980 believed this.¹⁷

The perception of prejudice, of course, is not proof of its existence. But, as shown elsewhere in this issue by Lynn Rose (p 586),¹⁸ the two tend to coexist, and each is disabling. Rose's study of homophobia among doctors is welcome and begs the question of how a profession that fails to care for its peers can care for its clients.

A change in attitudes and practice is overdue. Firstly, the needs of lesbians and gay men should be explored within undergraduate and postgraduate medical education. Models for medical undergraduates and mental health professionals^19,20 already exist, and evidence suggests that specific training is worthwhile.²¹

Secondly, points of contact should be established between service providers and the gay community, using existing resources within community mental health services and primary care. Gay or lesbian staff may or may not want to take on specific responsibilities. The costs of providing a poster, leaflet, or list of local groups are minimal. Thirdly, the government must review its own agenda in the light of the recent Department of Health booklet identifying sexual orientation as a risk factor for suicide in adolescents.²²

Finally, the Royal College of Psychiatrists needs to formulate a substantive response to the 1993 position statement on homosexuality issued by the American Psychiatric Association: "Whereas homosexuality per se implies no impairment in judgment, stability, reliability, or general social or vocational capabilities, the APA calls on all international health organizations, psychiatric organizations, and individual psychiatrists in other countries, to do all that is possible to decrease the stigma related to homosexuality wherever and whenever it may occur."²³

P McColl 

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