Another holiday season goes in the books…not the least of which are the check books. Our family has developed a tradition of attending a movie on Christmas evening, that is, by those who have sufficiently recovered from the materialistic orgy of gift giving and gluttony. Since wife and I no longer host the activities, I felt energetic enough to accompany the movie goers this year. Of course I was counting on deferential treatment for this old patriarch, and was not disappointed, for I was deposited at the theater entrance while a grandson parked the car. Fortunately, this provided just enough time for me to purchase tickets for the group.
The movie we had chosen was The Imitation Game, which provoked some painful memories for me. For those unfamiliar with the story, it is about the person who was able to break the German code in World War II, and is credited with designing the precursor to modern computers. As portrayed in the movie, the main character exhibited symptoms suggestive of a diagnosis of Asperger’s syndrome. He was also homosexual, “outed” by British police, charged with “indecent behavior,” chose chemical castration in lieu of incarceration, and eventually committed suicide.
The story reminded me of a major failure of mine as a psychiatrist many years ago. Bryan (not his real name of course) was a freshman at the university where I was teaching. His chief complaint was depression with rather typical symptoms such as: insomnia, loss of appetite, restricted interests, weight loss, the inability to experience pleasure, impaired concentration, and self-deprecation. In those days, depression was characterized either as Reactive or Endogenous. As the word suggests, the former title was reserved for those patients who had experienced trauma of some kind such as grief or other kind of loss, while the latter referred to those for whom no explanation could be found to explain their illness.
Initially Bryan’s depression seemed to be without cause and therefore endogenous. As a matter of fact, it seemed that he should be sitting on top of the world. He was a very handsome young man with blond hair and muscular build. He had been valedictorian of his class, the quarterback of his football team and the president of his high school class. He soon confessed, however, that he had recently participated in a sexual encounter with another male student, which left him immersed in shame and guilt for he said he never wanted to be a “queer.” He did acknowledge that he had always been attracted to males, but had previously been able to suppress and ignore those feelings. However a few beers at a fraternity party had allowed him to act out impulsively with devastating results.
Bryan’s Call for Help
After a few visits with little change, he arrived one day, and announced that he was feeling much better, and had decided to quit school to look for work in his hometown. I of course questioned such a drastic decision especially since in the face of depression judgment is often impaired. He assured me that he was no longer depressed and felt much better since deciding to change the course of his life. Several weeks passed until one day I received a call from his Mother who wanted to see me in person to talk about Bryan. As promised, Bryan had quit school, and gone home but not to look for a job. Shortly after his last visit with me, he had shot himself in the head. Fortunately or unfortunately depending on one’s point of view he did not die and after several weeks in the hospital was placed in a nursing home. Mother reported that he had suffered severe brain damage, and was in her words a “vegetable” with no hope of improvement.
The Pain of Hindsight
My thoughts went immediately to that last visit, and I realized my blunder in not decoding Bryan’s message. For he was telling me that he had found a terrible solution to his problem, and I should have suspected that such a sudden cure from depression of this magnitude was extremely unlikely, and probably was what has been called by psychiatrists a “flight into health”. Studies have shown that suicidal patients frequently send such coded messages prior to attempting to kill themselves. They seem to be rolling the dice to see if anyone will notice, perhaps retaining a faint glimmer of hope that someone might still be able to rescue them from their torment. I also theorized that his termination of our relationship was designed to release him from the promises he had made to me that he would not act out his suicidal thoughts.
Depression: What It Is and What It Isn’t. What Helps and What Doesn’t.
At the risk of digressing from my story, I feel the need to talk about depression and suicide. It is unfortunate that the word depression is used to describe a group of very serious, often fatal illnesses, which are often confused with the transient feelings of sadness we all experience from time to time. This leads to a great deal of misunderstanding by most people as to what we as psychiatrists mean by depression, and often leads to delay in treatment. We use a number of adjectives such as: melancholic, bipolar, unipolar, major, etc. to differentiate different types of depression, but the one thing they all have in common is that the course of the afflicted person’s illness is beyond his/her control.
Consequently; advice such as, “go have some fun, don’t take yourself so seriously, stop worrying so much,” and my all time favorite “you need to trust more in God” are apt to worsen the situation. Suggesting such remedies is much like advising a person with a broken arm to go lift weights. The fact that the person is unable to do these simple things further depresses self-esteem which is already at a low ebb.
Much as we who are treating have a semantic problem in labeling, our patients have a problem in describing their symptoms for I don’t believe there are any words in the English language that can adequately describe the torment of the clinically depressed patient. The more seriously depressed are often literally at a loss for words. I have seen patients with histories of medical problems resulting in excruciating physical pain who tell me that it was nothing compared to the suffering endured by an episode of clinical depression. No wonder that the CIA chose two psychologists to design a protocol for their “enhanced interrogation,” for depressed patients often describe their condition as torture. Faced with such intolerable torment and hopelessness, it is not surprising that one might choose the only avenue left.
Indeed, the lack of hope in a depressed person is one of the risk factors for suicide. Untreated clinical depression carries a mortality rate of nearly 20%, but is not often treated as a potentially fatal disease.
Much has been written in the lay literature about suicide, but much more needs to be done. Suicide is endemic throughout the world, and the incidence varies little in different parts of the world. 1The Center for disease control reports 40,600 suicides in 2012, but the actual incidence is certainly much higher as there are many incentives to deny the true cause of such deaths.
Suicide remains the 4th leading cause of death among children and young adults, and the epidemic of suicides among returning veterans has finally gained some notice. The loss of life is only part of the tragedy of suicide. Families have a grief enhanced by questions such as: What could I have done, Why didn’t he tell me? The grief and guilt are often laced with the anger of having been abandoned. In my experience the pain suffered by parents of child suicides is by far the most intense. As one parent told me several years after losing her child, you never get over it, you just learn to live with it.
When Was Homosexuality Demonized?
Anthropologists have reported that many so called primitive societies (that term may be one of those pot kettle things) were accepting of homosexual behavior and in some instances homosexuals were venerated.
John Boswell2 and Scott Bidstrup3 allege it was not until the 12th Century that homosexuality came to be regarded as immoral, and subsequently was made illegal. Bidstrup holds the Christian church responsible for those judgments, and sees them as the genesis for the homophobia which still persists to some degree. It should be noted however that the Torah4 prescribes death as punishment for sex between two men or two women; although some scholars insist this was meant to apply only to certain pagan practices. In the New Testament Romans 1”26-27 is frequently used as proof of the sinful and immoral nature of homosexuality but again others disagree with that interpretation. There have always been disagreements amongst scholars and lay people alike regarding scriptural meanings, and nowhere is this more apparent than with the issue of homosexuality. My own personal opinion is that these interpretations are strongly influenced by one’s political view as people of a more liberal bent generally appear to be more accepting. There is ample evidence that homosexuality has always existed regardless of the culture, and its prohibitions, and its incidence does not vary a great deal.
Whenever I see on TV gay couples being married or hear of a gay pride parade, my thoughts often turn to Bryan. I wonder if he had lived in a time when the homosexual label was less toxic, and he had not been conditioned to view it as repugnant and shameful, would he have lived to fulfill the promise that his life seemed to hold for him.
Homophobia in the Old Days
I must confess that I was a classic homophobe early on in my life. Although, I did not approve of gay bashing which some thought was a fun way to spend a Saturday evening, awareness of its happening did not seem to bother me much in those days. I recall that being called Queer was worse than sissy; although in my case I had no idea what the former meant. Sex was a taboo subject in those days except between adolescent boys whose testosterone levels were heading for the stratosphere. The “F” word was considered the most profane utterance of all, and would only be heard in secure facilities such as the boy’s locker room. By high school awareness of male attraction to males came to the fore, and should one, heaven forbid, develop an erection in the post game shower, he became immediately suspect and would likely be shunned. In those days a guy would likely receive more respect as an axe murderer than as a homosexual. I imagine the same attitudes were still in place during Bryan’s time, and I picture him attempting to avoid any glances at his team mate’s anatomy. Come to think of it, such behavior is not unique as can be witnessed by observing a group of men relieving themselves at a row of urinals. Without exception, they will all be staring straight ahead as if there is something particularly interesting on the wall. It is as if to look down at another man’s genitalia would signify a prurient interest.
After becoming a physician and later a psychiatrist I became aware of the multitude of serious problems facing the male homosexual. For most the fear of discovery was always with them. After all there were so called sodomy laws some of which remain on the books in a few jurisdictions; although generally no longer enforced. There was widespread discrimination in hiring. For those fortunate enough to have a job, outing could result in its loss. Long term relationships were not common, since living with another man was sure to raise eyebrows. Consequently; multiple sexual partners were common which put them at greater risk for venereal diseases. As mentioned previously gay bashing was a popular sport among some homophobes, and was rarely prosecuted unless it resulted in death. Some religious groups considered them evil and others saw them as simply disgusting. Ridicule and denigration were not unusual. The cruelest cut of all was for those who were ostracized by their family when their sexual identity was revealed. At a time in their lives when they most needed love and support, they were recipients of rejection and shame.
There were a few openly gay people, but most chose to remain secretive for obvious reasons. Bisexuals were able to maintain the charade of heterosexuality in most cases, marry and be seen as traditional family men. Some with a more fixed sexual identity would also marry as a means to cover their sexuality or as an attempt to “cure” themselves. Needless to say such unions were rarely successful. Some estimate the incidence of homosexuality to be as high as seven per cent, and since their lives were usually quite stressful the incidence of depression, and anxiety disorders was in my experience significantly higher than that seen in the population at large. The result of which was that there were more patients with problems arising from their sexual identity than one might expect.
Homosexuality: Nature or Nurture?
During my more than fifty years in the practice of general medicine and psychiatry, the one thing all those patients had in common was their insistence that they had not chosen to be homosexual. Almost without exception when I asked my homosexual patients when they had become aware of their sexual orientation, their response was that they had always known they were different. They felt it was not a learned behavior, but something they were born with. Since Freud appeared on the scene over one hundred years ago, there has been a running debate as to the roles played by early childhood experiences versus genetics in human development, (the so called “nature, nurture controversy”). Nowhere has the debate been more strident than in the areas of sexual identity and sexual orientation.
Freud’s formulation of the genesis of homosexuality was that normal psychosexual development was inhibited when a child grew up in a household where the mother was simultaneously seductive, but cold and rejecting, while the father was emotionally distant and uninvolved. His views were widely accepted, but there were critics who insisted that these psychodynamics could not be elicited in many cases. During the last half of the 20th century there developed more interest in brain function as it relates to mental disorders, personality development etc. This new field of neuroendocrinology with its high tech methods of studying brain function called into question many of Freud’s theories, and resulted in the development of many medications which have been lifesaving for many. One eminent psychiatrist went so far as to declare the talking therapies obsolete, and many training programs deemphasized the teaching of the various psychotherapies. It is true that there have been amazing progress in understanding how our brains function. The discovery of DNA and mapping of the human genome have opened new exciting vistas for the study of human behavior and its problems.
Call me old fashioned (which of course I am), but I remain convinced that the hand that offers the pill is also important. Man’s ability to form mutually dependent relationships was an important factor in the survival of the species. I am convinced that the computer which gathers a patient’s history although accurate is not as effective as a concerned human being. Brain scans may allow us to visualize certain feelings, but doesn’t show much empathy. Recently, I have been heartened to read pleas for more psychotherapy training for psychiatry residents in some journals. I am hopeful this may be a prelude to a return to a more equal swing of that nature-nurture pendulum. Among the population at large, the distinction of the classic debate is important. The major question as whether homosexuality is predetermined or developmental remains unanswered. Gay rights activists hold that homosexuality is merely a normal variation in one’s psychological makeup which is no more in their control than is the color of their skin; therefore genetically determined. Others consider it to be immoral, while some of the more zealous religious groups still consider it a sin. Regardless of etiology, there is general consensus in the psychiatric community that one’s sexual proclivities are not subject to change. There are some who claim success in their efforts to change a person’s sexual orientation, but others refute these reports and suggest they are only teaching their subjects to repress their urges.
Hope for the Future?
Since Bryan’s day there have been remarkable changes in our society’s attitudes towards homosexuality; although that is not to say that discrimination and homophobia has been banished. The enlightenment had its origins when the gay community organized and attached themselves to the coat tails of the civil rights movement of the sixties. The political boldness of this group contributed to and was enhanced by several well known public figures who “came out of the closet” and reported they felt liberated by their decision. I vividly recall the hallabaloo in the press when Billy Jean King announced to the world that she was a lesbian. This was in marked contrast to the recent outing of Anderson Cooper which hardly caused a whimper. There was as expected a backlash in those early days of the movement, and one of my other vague memories of those times is of a gay man who was tied to a fence pot and beaten to death by two rednecks.
In 1972 my own professional organization, The American Psychiatric Association, in an apparent response to political pressure deleted homosexuality from the list of mental disorders in 6DSM III (The Diagnostic and Statistical Manual of Mental Illness). They resolved their ambivalence about causation by adding the term “Homosexual dysphoria” referring to mood problems associated with homosexuality. The response of the membership was mixed with some praising the leadership and others expressing concerns that the organization was abandoning scientific principles for political correctness, and that the new term was simply an attempt at fence straddling.
The march towards gay rights was slowed by the aides epidemic, which was originally called the gay disease. One prominent TV evangelist went so far as to label the disease as God’s punishment of gays for their sins, and equated it to the story of Sodom and Gomorrah. Although less evident discrimination is not hard to find even though examples are less obvious. One such case was brought to my attention shortly before my recent retirement. The patient was a young man who was angry, depressed and anxious. He was employed in a factory where he told me he had received awards for his productivity; however that was to change after it became known that he was homosexual. He was continually harassed teased and belittled. His work bench was sabotaged. He was routinely addressed as faggot or queer, and was shunned in the lunch room. He decided to take his problem to the human services department where he received only token acknowledgment, and later heard his supervisor refer to him as a “fag trouble maker”. He sought legal redress for the discrimination in which he thought his employer was complicit. This accomplished little other than to deplete his savings with legal fees. With the abusive behaviors unchecked they escalated until the stress became intolerable and he quit his job. His employer refused to okay his application for unemployment compensation.
In spite of such incidents, which are hopefully isolated, there are hopeful signs that things are changing for the better. The gay community has become organized and is no longer powerless. There is a new openness regarding sexual identity, and fewer reasons to remain in the shadows. In recent years I have noted that my patients are rarely apologetic for their sexuality, and in most cases have accepted it. With this newfound openness, there appears to be more long term relationships. Polls show that in the past few years there has been a demonstrable increase in the acceptance of gay marriages, and a relaxation by some courts on the bans against gay parenthood. The most hopeful sign for the future; however, is the fact that homophobia appears to have been drastically reduced among young people.
It has pleased me to witness more dramatic changes in attitudes in the past 50 years than have occurred in the previous several hundred. They come too late for Bryan; however they may be life saving for others. That is important as the world is in great need of their sensitivity and creativity.
1Centers for Disease Control and Prevention; Fatal injury Report 2012
2Boswell, John; The church and the homosexual an historical perspective
3Bidstrup,Scott; Saint Aelred the Queer
6The diagnostic status of homosexuality in DSM III: a reformulation perspective; Amerrican Journal of Psychiatry: Volume 138 issue 2 February 1981 pp. 210-215