Medical aspects of homosexuality
Antonio Pardo.
department de Bioética, University of Navarra.
Published in the journal Nuestro Tiempo, July-August 1995, pp. 82-89.
Contents
I. Animal "homosexuality
II. Human sexual behaviour
III. "The homosexuality gene".
IV. The role of the doctor
Recently, homosexuality has been the subject of several scientific articles that have been reported in the press with sensationalist headlines that did not adequately reflect the nature of the findings. In this article I will attempt to clarify what medicine knows and does not know about homosexuality. Explaining this issue requires bringing together knowledge of neurophysiology, genetics, education, psychology and ethics.
Although it is perhaps a simplification, we could say that a homosexual is a person who, in his or her sexual tendency and behaviour, sample is inclined towards persons of the same sex1. This definition allows us to clarify some issues from entrance .
The first is that, strictly speaking, there is no homosexuality in animals. But this does not imply that their behaviour is exclusively heterosexual. In fact, it has been observed that animal sexual behaviour, at least in the most evolved mammals, is very variegated: in addition to the complex physiological control of reproduction (especially hormonal)2, behavioural factors other than purely reproductive ones are involved in animal sexual behaviour. In particular, play during juvenile age (primates), or behaviours of submission to dominant males during adulthood (canids, etc.) may be involved. Furthermore, life in captivity, by removing many stimuli from the wild, leads to a higher frequency of sexual behaviour between individuals of the same sex, as breeders are well aware3. There is, therefore, an interaction of various instinctive drives and environmental circumstances that end up shaping animal sexual behaviour.
For reasons of survival, the reproductive instinct of animals is always directed towards individuals of the opposite sex. Therefore, the animal can never be properly homosexual. However, interaction with other instincts (especially dominance) can produce behaviour that manifests itself as homosexual. Such behaviours do not amount to animal homosexuality: they mean that animal sexual behaviour includes, in addition to reproductive behaviour, other dimensions.
Human sexual behaviour is more complex than animal sexual behaviour; although the latter can teach us about some aspects present in man, there are elements of human sexual behaviour that are not present in animals. We will mention the three most relevant ones.
The main one is that human sexual behaviour (like any other human behaviour) can be subject to decision, it can be acted upon or not. Such a decision is not within the animal's capacity: it is driven by its instinctual drives and environmental circumstances4. For this reason, human behaviour is in a permanent tension between tendencies and decisions. Human education is not, as in animals, domestication (creation of conditioning based on instincts), but the cultivation of intelligence and affectivity that allows man to decide freely, so that he can resist his inclinations when they hinder him from acting well, or encourage them when they help him (think of the control of anger to allow social coexistence or the encouragement of maternal affection to allow the education of children).
The second element is man's relative independence from the environment in which he lives. While the animal depends on its full physical and instinctive endowment to survive, man can tolerate serious physical and tendential deficiencies, because he relies on his intelligence to solve the problems that life poses. Thus, while each animal is adapted to a specific environment and cannot survive outside it, man is found all over the planet5. For this reason, man's behaviour-related genes are not, like those of animals, exquisitely controlled by external circumstances. In the case of man, the innate tendencies, linked to the genetic endowment, can to a certain extent be disengaged, without this putting the species in danger of extinction: intelligence supplements. Thus, in the field of sexuality, while an animal with an instinctive error in its sexual behaviour does not reproduce, a human being with an innate inclination not directed towards the other sex can do so, and can thus pass on its altered natural endowment. Because of this second factor (inheritance not governed exclusively by the environment) there can be true innate homosexuality in man, which would be impossible in an animal.
And thirdly, the human psychological development does not consist of the simple interaction of innate inclinations and free decisions: education is also involved. In the field of sexuality, within the educational influence, we must include the psycho-affective development , which is decisively influenced by the family environment. In fact, the existence of family psychopathology (hyperprotective mother and indifferent father, etc.)6has been postulated as one of the possible causes of homosexuality (psychological in this case).
This view of human behaviour as an integrated set of intellectual, physical and psycho-affective aspects has not been properly appreciated throughout history. There have been exclusionary versions of homosexuality: spiritualist (such behaviour is only the result of a personal decision), biologist (it is only the result of a peculiar genetic or neuroanatomical endowment), or cultural (it is only the result of education or psycho-affective conditioning factors). Each of these three interpretations values the homosexual in a different way. In the first case, the homosexual is only guilty. In the second, he is an innocent puppet of his altered tendencies. In the third, he has suffered, to his regret, a negative external influence.
However, any of these interpretations is simplistic. Man's behaviour is not result only of decisions, not only of innate drives, not only of inculcated habits, but is result of a complex interaction of these factors: genetically determined drives and decisions, both modulated by the received education (including under this term both psychological and ethical aspects). No consideration of homosexuality that leaves out any of these facets is in a position to deal adequately with the facts: it will misinterpret them and give homosexuals false solutions to their problems.
III. "The homosexuality gene". 
Until recently, the intellectualist interpretation (homosexuality is only the result of a decision) was the most widespread. Perhaps as a reaction, in recent times the emphasis has shifted towards the purely biological, and the scientific search for genetic or structural differences between homosexual and heterosexual persons has begun. This research is fraught with difficulties, as it must always take into account the multifactorial origin of human behaviour7.
Recent findings, and above all those that have most captivated public opinion, are those that associate homosexual behaviour with alterations in brain structure or genes.
The first of these studies to become famous was that of LeVay8. His work analysed the development of the so-called interstitial nuclei, four groups of neurons in the anterior area of the hypothalamus. He found that, of the four nuclei, number 3 was smaller in homosexual males than in heterosexual males (it was already known to be smaller in females than in males). However, this study is not definitive: the number of brains studied was small, and almost all came from AIDS patients. It remains to be established whether this morphological alteration is a constitutional trait and not an effect of the infection. Moreover, even if the former were proven, we would still be in the dark as to its significance: it will be necessary to clarify what subject connection there may be between this anatomical difference and sexual orientation. Indeed, recent work has questioned, with considerable justification, whether the interstitial nuclei are related to sexual orientation, and whether it would not be more reasonable to investigate other brain areas9.
The other study was conducted by Hamer10 , who analysed the relationship between male sexual orientation and a genetic marker on the X chromosome. He and his team investigated the family trees of 114 families with a homosexual member and tried to establish a rule of kinship between members with a homosexual tendency. It seems that there may be a genetic factor linked to the X chromosome (of which males possess one and females two). To test this hypothesis, he carried out a genetic study in 40 families using a DNA marker specific to this region of the X chromosome, and found that there was a link between the presence of this marker on the X chromosome and homosexual behaviour.
This study does not mean, however, that the gene for homosexuality has been identified: as mentioned above, given the complexity of sexual behaviour, it is highly unlikely that male sexual orientation depends on a single gene. This finding is only an initial test that there is a genetic factor or factors linked to male homosexuality. But it remains unknown which gene or genes are involved, or how they influence behaviour. And, clearly, the knowledge of this data does not put us in a position to deal with altered sexual inclination.
Unfortunately, these data are not sufficient to clarify the biological problem underlying homosexuality. The question is still obscure, all this research is only in its infancy, and we do not know where it will lead. As we saw earlier, sexual behaviour is, from the biological point of view, result of a complex interaction of several tendencies; therefore, the finding of a single factor gives us very little light on which genetic disorders (with the consequent neurological, hormonal, etc. modifications) are the cause of the homosexual tendency, although it is a way to know. It would also be necessary to know other genes that guide juvenile gambling behaviour, relationship behaviour, etc.
To make matters worse, in men, these biological studies are hampered by their decision-making capacity: to give an example from another subject, not every genetic alteration that determines greater male aggressiveness (trisomy XYY) produces aggressive behaviour, because men can overcome their inclinations. These are, in short, extraordinarily difficult studies, which do not seem to have a clear answer in the short term. In fact, the mere existence of different psychological types of homosexuals, with a predominance of the feminine tendency to subjugation, or of the social tendency to dominance11 , sample , shows the complexity of the problem: homosexuality cannot simply be attributed to a single cause, and even less to a single biological cause.
In terms of medical care, homosexuality poses essentially two problems, one of which is currently of enormous prevalence: AIDS, whose enormous repercussions are beyond the scope of this article. The other is to treat the psychological disorders of this subject group of people12. However, the doctor is not confronted with these patients with a mere psychological problem (anxiety, etc.), unrelated to homosexual behaviour. This deserves a brief explanation.
Medicine does not pursue human happiness. That is a question that has traditionally been dealt with by ethics and religion: to know what is the freely decided conduct that leads man to his human fulfilment. The physician deals only with the medical aspects of human life: health and illness. The physician is not a moral counsellor.
However, the doctor, when trying to treat his patients, cannot ignore the fact that they are men, with decision-making capacity and, therefore, with moral issues in their lives, which, especially in patients who come to the psychiatrist, can have a strong relationship with psychological disorders. There are trends in psychiatry, currently quite widespread, which consider the patient's behaviour to be ethically irrelevant at subject sexual. Consequently, in an attempt to eliminate the ethical factor, homosexual inclination has been removed from the lists of psychiatric illnesses13 while, paradoxically, other deviations of sexual tendencies (paedophilia, voyeurism, etc.) have been left in place.
The following course of action seems more coherent: the physician, when his patient presents with a problem of homosexuality, has an obligation to treat him. He should not discriminate against him on the basis of his sexual orientation or inclination: the physician owes an equal duty to all his patients. However, such equality of treatment does not mean indifference to the lifestyle of the patient. For the physician knows that this lifestyle may have a very direct bearing on the psychological problems afflicting the patient. To reduce the problem to its purely psychological dimension is medical incompetence.
The psychiatric school of Victor Frankl has given its name to the approach which takes into account this human aspect of the patient: logotherapy14. Its basic idea is to affirm that the free decision of the will can have a very important influence on psychopathology. Consequently, he does not disdain to set the patient a demanding horizon if he sees that a humanly inadequate approach of personal life is at the root of his psychological problems. It is not unrealistic for the doctor to ask his patient to control himself and his tendency towards people of the same sex. In the same way that control of the tendency towards the opposite sex is possible in those who do not suffer from a disturbance of the heterosexual tendency, the possibility should be open to this subject of committee in the case of homosexuality. To pose sexuality as a completely irrepressible exercise is a humanly wrong and unrealistic approach . In fact, it is normal for a man to be the master of his actions; why exclude homosexual sexuality from this general law?
Sometimes the psychological problems of this subject group of patients stem from their lack of self-control. Undoubtedly, the experience of same-sex tendencies is disturbing enough. But if to this factor is added an unbridled practice of sexuality, the feeling of guilt increases, and it is difficult to maintain psychological stability: it is necessary to see a doctor. Therefore, the correct medical care for these patients must include an attempt to restore their self-confidence, an attempt that involves offering the patient, in a manner appropriate to their circumstances, control of their peculiar inclination15.
Notes
(1) Gelder defines it as "erotic thoughts and desires towards a person of the same sex and any associated sexual behaviour". Gelder M, Gath D, Mayou R. Psychiatry. 2nd edition. Mexico, Interamericana, 1993, p. 547.
(2) Ponz F. Animal behaviour and higher brain functions. Language. In: Balasch J et al. Fundamentos de Fisiología animal. Eunsa, 1979, p. 196.
(3) Goodman RE. Homosexuality. BMJ 1988; 297: 738.
(4) Ponz F. op. cit., p. 197.
(5) Polo L. On the origin of man: Hominisation and humanisation. Rev Med Univ Navarra 1994; 39: 41-47.
(6) Levine SB. Sexual Life. A clinician's guide. New York, Plenum Press, 1992, p. 163 ff.
(7) Bancroft J. Homosexual Orientation. The search for a biological basis (publishing house). British Journal of Psychiatry 1994; 164: 437-40.
(8) LeVay S. A Difference in Hypothalamic Structure Between Heterosexual and Homosexual Men. Science 1991; 253: 1034-7.
(9) Gorman MR. Male homosexual desire: neurological investigations and scientific bias. Perspectives in Biology and Medicine 1994; 38 (1): 61-81.
(10) Hamer DH, Hu S, Magnuson VL, Hu N, Pattatucci AML. A Linkage Between DNA Markers on the X Chromosome and Male Sexual Orientation. Science 1993; 261: 321-7.
(11) Guasch Andreu O. Homophilic types: an approach to homosexual recognition and interclassification codes. Janus 1987; 32: 1919-28.
(12) Cf. Gelder, op. cit., p. 551.
(13) Homosexuality, although still the subject of a chapter in psychiatry textbooks, does not appear in the latest edition of the DSM or in the ICD. DSM-IV (Diagnostic and Statistical guide of Mental Disorders. Fourth Edition). American Psychiatric Association. Washington DC, 1994, 886 pp. ICD10 (Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines). WHO, Madrid, 1992, 424 pp.
(14) Frankl VE. The Doctor and the Soul. From Psychotherapy to Logotherapy. New York: Vintage, 1986; 318.
(15) Lister J. Homosexuality and Prostitution. NEJM 1956; 254: 381-2.