A Critique of the Writings of Richard Isay
Joseph Berger, M.D.
Introduction
Richard Isay is a psychoanalyst who in recent years has been a vehement critic of the traditional psychodynamic approach to homosexuality. In a number of papers, Isay has put forward two principal positions. First, he has challenged the notion that homosexuality represents a failure to achieve full psychosexual developmental maturity. Second, he has also attempted to reject the notion that anyone who may have had homosexual experiences, thoughts, or desires, can be helped by psychotherapeutic or psychoanalytic treatment.
Not only has he claimed that "the effort to change the sexual orientation of gay patients is not clinically helpful. . . core sexual orientation remains unchanged . . . attempts to change (it) are, in all likelihood, futile,"{1} but he has asserted that "efforts to change homosexuals to heterosexuals, I believe, represent one of the most flagrant and frequent abuses of psychiatry in America today."{2}
Purpose
In this paper I intend to discuss the scientific foundations upon which Isay bases some of his claims, the clinical material that he presents, his own attitudes towards the work and findings of other therapists, and the conclusions that he comes to.
Isay's Reliance On Claims for Biological Foundations
In a recent prominent but inflammatory article,{3} Isay indicated that he accepted the claims suggesting that there was a biological basis for male homosexuality, put forward by LeVay,{4} and Bailey and Pillard.{5} In May 1995, Isay appeared together on the same side as Hamer at a panel debate about the origins of homosexuality, apparently accepting the claims put forward by Hamer and his colleagues.{6} Unfortunately, none of the claims and work of these authors has been repeated and confirmed by others.
The methodology of some of these studies was shoddy, the claims were grossly exaggerated, the corroborative references brought by Bailey and Pillard did not support their conclusions, and the declared personal biases of these authors was to say the least, scientifically questionable.
These papers were published in conjunction with media publicity of a highly political nature{7} that raised serious questions about the scientific neutrality and credibility of the authors. Not only have the claims made in these papers not yet received any scientific confirmation, but serious errors and inadequacies have been convincingly demonstrated.{8}
Ubiquity and Normality of Homosexuality?
In his earlier writings, Isay brought other material that he believed supported his case, but that has come under extensive criticism. Isay quoted a 1951 statement by Ford and Beach{9} that "a biological tendency for inversion of sexual behavior is inherent in most if not all mammals," but he did not quote Beach's later rejection of that earlier view in a 1971 interview. "I don't know any authenticated instance of males or females in the animal world preferring a homosexual partner—if by homosexual you mean complete sexual relations including climax . . . it's questionable that mounting in itself can properly be called sexual."{10}
Isay has also quoted the well-known, frequently referred-to study by Hooker{11} that supposedly showed the absence of significant psychopathology in homosexuals. Though Hooker's claims are frequently cited as proof of the psychological "normality" of homosexuals, and of the absence of any demonstrable psychological differences between heterosexual and homosexual people, a number of years ago those claims were refuted by Fine and Bieber, who reviewed Hooker's claims and test results.{12} But Isay, of course, has not quoted these rebuttals.
Isay, in common with most other gay activists, has referred to the vote of the American Psychiatric Association in 1973-1974, that led to removing homosexuality per se from the Diagnostic and Statistical Manual of Mental Disorders. However, Isay does not acknowledge the true story that others writing before him had already revealed, which was that the National Gay Task Force, a homosexual lobbying group, had organized and underwritten the cost of mailing a crucial lobbying letter to the membership signed by the candidates for senior office and sent to all members just a few days before the vote, recommending acceptance of the Board of Trustees decision.{13} It is rather surprising that a psychoanalyst would not explore the true reasons and forces behind a particular form of manifest behavior.
While Isay may not have been personally present (as I was) at subsequent appearances by North America's leading analytic theoretician, I hardly imagine that Isay was unaware that after the APA vote Otto Kernberg was saying to thunderous applause from huge audiences, "We do not decide scientific matters by vote." So Isay's initial position that homosexuality is something that is innate, biologically determined, has been based on insubstantial pillars.
Psychological Determination of Homosexuality:
If a particular form of behavior is not biologically determined, then the most likely possibility is that it is psychologically determined. To a considerable extent, the idea of the psychological determination of character or behavior is a default theory. In the absence of physical signs or other biological "markers" and given the uniqueness of each individual's upbringing and the impossibility of replicating it, we can only suppose that certain psychological factors might have contributed to a person's thoughts, feelings, or behavior.
Furthermore, our present level of understanding is almost entirely limited to a retrospective explanation of any such psychological determination. We have almost no ability to state prospectively that any particular paternal behavior and interaction will lead to any given outcome in a child of those parents, in the same manner that we can predict that certain physical lesions or abnormalities will almost always produce certain recognized outcomes.
The reality of homosexual desire and behavior provide a perfect example of this situation. We have an absence of any good evidence of physical or biological causation. Therefore, by default, we are left with the likelihood that psychological factors are responsible, and there is much to support this notion.
The fact that people who have previously been fully heterosexual in their desire and orientation but are temporarily deprived of contact with the opposite sex such as in prisons, may then participate in some homosexual experiences, only to revert immediately to regular heterosexuality when free to pursue such opportunities, is an indication that human sexual behavior is far from rigidly fixed at birth.
Similarly, many therapists, and many reports in the literature, have noted repeated examples of people apparently changing their sexual orientation at different times in their lives. Psychodynamic psychotherapists have offered coherent theories to explain why such shifts can occur, but for those who have proposed a biological basis for homosexual behavior, such events have cast considerable doubt on their theories.
The response of Isay, and those like him, has been to assert that the "true" sexual orientation of the person has not been clearly defined, or has been misunderstood or denied by a therapist or by the patient, with at times disastrous consequences.
As we shall see, not only does the absence of any widely-accepted "marker" make such assertions highly questionable and essentially scientifically unverifiable, but Isay's clinical material is quite unconvincing, and only confirms that claims about the "true" orientation of such patients are a highly contentious issue.
Is Homosexuality Reversible?
Nearly 15 years ago, Bieber and Bieber expressed concerns about the claims of homosexual propagandists on this matter. "Others claim that a true homosexual cannot change. Once the mold is set, it is unbreakable. Yet, they do not find this assertion at odds with their citations of persons who have changed from heterosexuality to homosexuality, sometimes as late as middle age."{14}
At the time their paper was published, Bieber and Bieber had seen well over 1000 male homosexuals, and had noted that "a substantial number do become and remain heterosexual.
Reversal estimates now range from 23% to an optimistic 50%." But, they noted, "Despite the treatment results we reported and the published findings of other respected colleagues, these cynics steadfastly refuse to place any credence in these reports."
Isay has become one of those "cynics" and repeats the assertion (which only confirms how accurate was the Biebers'insight many years earlier), even though the evidence contradicting the gay activist assertion that homosexuality is unchangeable is just overwhelming.
Most recently, MacIntosh has published a survey of 1215 homosexual patients who were seen for treatment by 285 psychoanalysts across the United States, and the analysts reported a success rate of change to comfortable heterosexuality of 23%.{15} Though some people have said that a success rate of 23% is not very high, given the assertions made by Isay and other homosexual extremists such as Goldberg{16} that homosexuality is "impossible to change . . . immutable," irreversible, even a 23% success rate is of profound significance, let alone that other therapists have reported higher success rates.
Isay's Definition of Homosexuality
To try to clarify this difficult area, it might be thought that a definition of homosexuality or a homosexual person would be helpful, and Isay has offered his definition. "I am emphasizing . . . that it is the erotic fantasy that defines the homosexual and not his behavior.''{17}
However, Isay's definition is contradicted by the work of Masters and his colleagues, and by the findings of Ellis and McConaghy. The Masters group noted that three criteria have usually been used to define a homosexual person, "same-sex attraction, same-sex sexual experience, and same-sex fantasy. However, none of these criteria has been empirically established as valid."{18}
They examined the fantasy patterns of 30 homosexual and 30 heterosexual men, and 30 homosexual and 30 heterosexual women from their nonclinical study subject population. They found that same-sex erotic imagery was one of the most frequent fantasies described by the heterosexual group, and opposite-sex imagery was even more frequently reported by the homosexual group. Thus, they conclude, "fantasy patterning is certainly suspect as a specific diagnostic criterion of sexual orientation."
Ellis et al{19} reported on a study of more than 400 young men and women who were asked about their sexual fantasies and sexual experience. At least one third of respondents of both sexes said that they had had same-sex fantasies.
McConaghy{20} also reported that in both male and female college-age students, well over 40% had same-sex fantasies. And an even higher percentage (well over 50% for each sex) of the students said that they had had such feelings before the age of 15.
Given the fact that most studies now estimate adult homosexuality as being the orientation of not more than 2-4% of the population, and possibly even less than that, a recent report from the Alan Guttmacher Institute found that only 1% of a large sample of American men in their 20's and 30's described themselves as being exclusively homosexual.{21} These results strongly suggest that erotic fantasy is not definitive for homosexuality.
What these studies also suggest is that polarizing sexual orientation into two total opposites, homosexual and heterosexual, is not helpful. Even though at each end of the spectrum exclusively heterosexual or exclusively homosexual individuals may be recognized, the sexual orientation of most people is more likely to be distributed along a continuum, to be more flexible, and responsive to internal or external pressures.
When I was in medical school some 30 years ago, I remember my professor of anatomy (Prof R.G.Harrison) telling us about a well-known South African anatomist, Phillip Tobias, who was also renowned for his humanity and political liberalism. In the days of apartheid in South Africa' he had evidently testified in a court case over an issue of `'colour" by bringing in 26 members of the same family, all related to each other, who ranged from the blackest of the black to the whitest of the white, with all shades of colour in between. While no-one would have difficulty deciding the "colour" of those at the extreme ends of the spectrum, the real problems lay with assigning designations to all those shades in between.
Isay's Clinical Material
But it is Isay's own reports of his therapeutic work that are most vulnerable to serious criticism. In a paper that first appeared in the Psychoanalytic Study of the Child{22} and was then modified for a text edited by Stein and Cohen,{23} he gives illustrations from patients he has worked with.
Isay starts that paper by attempting to demonstrate that the traditional psychoanalytic view of homosexuality has been that it is pathological. The quotations that he offers include some extreme statements, some from many years ago. He seems reluctant to acknowledge the process of evolution in understanding that has led to the rejection of the more extreme distortions. Neither is he prepared to accept the clinical accuracy of many of the other comments.
He chooses some quotations from Freud that would seem to indicate that Freud believed homosexuality to reflect incomplete psychosexual development, and to believe that some patients could be helped to become more comfortably heterosexual while in others that would be unlikely. Those position sound eminently reasonable today, but Isay appears to give them a different significance, suggesting that Freud did not see a developmental problem in homosexuality, and did not believe that some patients could be effectively treated. The very quotations Isay offers contradict his own interpretations.{24}
The clinical body of his paper then gives five examples of patients who Isay claims were misunderstood, misdiagnosed, or mistreated by other therapists. Isay claims that the other therapists caused "symptomatic depression," "severe social problems in later life," that the other therapists did not "convey an appropriate positive regard" for their patients, or "maintain therapeutic neutrality," and that these arose because of the therapist's "internalized social values" that interfered with the proper conduct of the therapy.{25}
Isay acknowledges{26} that "At some point in every intensive therapy, every gay patient expresses unhappiness and dissatisfaction with his homosexuality." Isay refuses to consider the possibility that such patients are expressing their deeper wishes to be truly, fully, comfortably heterosexual and are profoundly saddened, distressed, and frustrated by the blocks and difficulties that they know are hampering such fulfillment? He gives the impression that this expression of unhappiness and dissatisfaction is less authentic than identical expressions of unhappiness and dissatisfaction from so many of our other patients. He appears to imply that it should not be worked on.
The first patient Isay mentions was only 20 years old! Some authors would disagree that a patient's sexual identity is finally and rigidly fixed by that age.{27} This patient "complained of severe dysphoria, an inability to form any kind of satisfying, lasting relationship . . . having no goals in his life.... He also complained about being gay." Given the age of 20, these are hardly unusual complaints.
We are told that, "His parents wished he was straight. Mother badly wanted grandchildren. He wanted to be able to please her." He had had friendships with girls and had had sexual intercourse with one, but his fantasies had been mostly about boys.
Isay criticizes the previous therapist's approach. He believes that therapist coerced the patient towards heterosexual interests and expression because of the therapist's disapproval of homosexuality. The previous therapist, had understood the patient's comments and complaints about the therapist as being products of the patient's projection. But Isay believes, without any evidence, that the therapist was biased and shared the "values of a society perceived as being critical and ho stile ."{28}
Isay insists that he, in contrast, was "accepting . . . neutral . . . non judgmental." Unfortunately, his own writing indicates that Isay has been the total opposite. He has refused to accept the heterosexual strivings of such patients, he is most definitely not neutral but heavily biased and prohomosexual, and he has been highly judgmental of those who take a different viewpoint.
To many therapists, analyzing the young man's view of his first therapist as being based on projection would seem to be a reasonable evaluation, probably a correct conclusion! There is absolutely no evidence in the material we are given to support the notion that the young man's "feelings of self-loathing" arose "from internalized social prejudice."
The theme that these patients have "internalized critical social values" is mentioned a number of times by Isay, but it must be asked, does Isay have any evidence of real social criticism directed towards these patients? When Isay claims about another patient, "Some of the angry, destructive, rebellious activity related to his response to social attitudes has diminished?" we have to ask which "social attitudes" had the patient personally experienced that had given him difficulty? Is there any evidence for these claims or are they the author's prejudice?
Therapists who have worked with patients, especially late adolescents and young adults, have learned to be very careful when it comes to evaluating such claims. When a patient openly acknowledges never personally having been on the receiving end of prejudice and discrimination, it is not good enough to imply a vague collective unconscious. The therapist has to consider seriously the possibility that the patient is projecting, or over-identifying with parents.
The second patient, "B", provides another example of the bias that Isay brings to his work. The patient's age is not given, but in the absence of any adult indicators of career, it is possible that he was a late adolescent or young adult. We are told that he had "felt homosexual since childhood and had actively engaged in homosexual sex since early adolescence. He had neither heterosexual experience nor sexual interest in women." Isay has therefore set us up to believe that he was dealing here with an obviously homosexual young man who should never have received any questioning of his presumably early, fixed, unchangeable, undoubtedly biological, homosexuality. However, Isay does admit that the patient was quite troubled with his sexuality, with his desires, practices, and identity. Isay admits that the patient frequently said that, and clearly indicated his wish to explore the possibilities of becoming heterosexual.{29} Now whether that was technically possible remains debatable. I, and I am sure many other therapists, have had patients who came to us for help with many different motivations, but not all are good therapy candidates.
But the issue here is, are Isay's criticisms of the first therapist and praise of his own approach, justified?
It could be argued that the first therapist made an honest attempt to respond to the patient's manifest distress and dissatisfaction with his sexual fears and inhibitions, but the patient was not ready or appropriate for such an exploration. Isay makes it clear that the patient also frequently responded to him in a negative manner, and the impression we receive is that the therapy with Isay was not a great success.
Neither are Isay's claims about the patient's sexual orientation definitive, in my opinion. Homosexual desires or acts in childhood or adolescence are not unusual, nor definitive for adult sexuality, and there is an obvious contradiction between the lack of heterosexual interest and experience, and the great unhappiness with the adolescent-young adult homosexuality.That contradiction justifies therapeutic exploration in a capable and willing patient.
But it is the third patient, "C", who surely provokes the most profound challenges and questions about Isay's understandings and orientation. Mr. "C" was a 47 year old married man, the father of two daughters. He is described as "a devoted father and husband . . . he had a wife and children from whom he gained enormous pleasure. He liked the conventionality, the relative lack of stress in his life, and his professional success." He had had some homosexual experiences when younger, before an analysis and the subsequent marriage, but no homosexual experience since being married.{30} Isay admits, "He had no regrets over the change in his sexual behavior, except that he felt something was missing in his life—he called it a "passion." His presenting symptoms were, "depression, apathy, low self-esteem, lack of sexual interest in his wife." Isay is quite dogmatic about this patient. In spite of all evidence to the contrary, and in spite of numerous alternative possible explanations, Isay insists "C was still homosexual."
Many therapists deal with men and women in this age group who have very similar symptoms, who "long for the lost love of (their) youth," who feel 'isomething that they call a passion is missing in (their) life." Countless patients are like that. But most therapists usually explore the many issues that are so frequently present around aging, marital frustrations, work and career issues, deeper feelings of success or failure, whether a person has been able to reach very private inner goals that may have been unrealistic. Also, teenage daughters not infrequently provoke conflict, especially in middle-aged fathers whose own sexual life is not satisfactory and fulfilling. It is quite possible that another therapist would have explored some of these areas with Mr. "C", and possibly have involved his wife in a joint therapy to look at the marriage and the absence of sexual activity.
Because of Isay's bias, Mr. "C" seems to have been left asexual. It is quite possible that with a therapist who was not so committed to a homosexual framework but worked in a more therapeutic manner, that Mr. "C" might have been better able to work through some of the deeper reasons for his depression and apathy, and come to a more fulfilling outcome, including that of a healthy sex life.
Patient "D", a married but separated man in his late thirties, had been depressed and had homosexual experiences when younger, but through an earlier analysis had recovered from depression and met and married a woman. To many therapists, he would seem to have been clearly heterosexual' retreating from comfortable heterosexuality when his sense of self, and pride and enjoyment in his work and activities were diminished or undermined.{31} The adaptational approach of Ovesey and his colleagues remains very helpful in understanding and treating such patients.{32}
Therapy would therefore be directed towards exploring with such a patient when and how he comes to feel that way, and the effects it has on his sexuality. Possibly, the early origins of why he would search for a man, might emerge. There are a number of psychodynamic possibilities, the well-known ones include a wish for a powerful father to "take over" and help the patient back on to the "right path," provide the strength, support, reassurance, etc. that the patient seeks. There may be wishes to be loved, admired, respected by a man in a way that was missing in childhood.
Isay chooses to take a completely opposite approach in interpreting the material. He claims that the patient was always homosexual and remained so, implying that the marriage was a mistake undertaken under "pressure" Dom a biased analyst. The symptoms that brought the patient to Isay were therefore a consequence of the stress of living such a lie. During therapy with Isay he resumed active homosexual behavior.
Notes
{1}Isay, R. A. (1988). Homosexuality in Heterosexual and Homosexual Men. Psychiatric~lnnals, 18(1). pp. 43-46.
{2}Isay,R.A. (Feb.7, 1992). Psychiatric News,p. 17.
{3}Ibid.
{4}LeVay, S. (199l). Science, 253, pp. 1034.
{5}Bailey, J. M. and Pillard, R. C. (1991). A genetic study of Male Sexual Orientation. Archives of General Psychiatry, 48. pp. 1089-1096.
{6}Hamer, D. H. et al. (1993). Science. 261. pp. 321-327.
{7}Bailey, J. M. and Pillard, R. C. (Dec. 17, 1991). New York Times.
{8}See Socarides, C. (1995). A Freedom Too Far. Phoenix. Adam Margrave Books.
{9}Ford, C. S. and Beach, F. A. (1951). Patterns of Sexual Behavior. New York, Harper.
{10}See Socarides,C.(1978). Homosexuality. New York. Jason Aronson, pp.34.
{11}Hooker, E. et al. (1969). Final Report of the NIHM Task Force on Homosexuality.
{12}Appendix A. Fine,R. and Appendix AA. Bieber,T.B. (1973). Homosexualityin the Male: A Report of a Psychiatric Study Group. ~ternatFonal Journal of Psychiatry. pp. 471-478.
{13}See Socarides, C. "A Freedom Too Far." loc cit. and Rueda, E. T. (l 982). The Homosexual Network. Connecticut. The Devin Adair Company.
{14}Bieber, I. and Beiber,T. B. (1979). "Male Homosexuality." Canadian Journal of Psychiatry. 24(5). pp.409-421.
{15}McIntosh, H. (1994). "Attitudes and Experiences of Psychoanalysts in Analyzing Homosexual Patients." Journal of the American Psychoanalytic Association. 42 pp. 1183-1205.
{16}Goldberg, J. (1995~. "Missionary Positions." American Journal of Psychoanalysis. 55. pp. 121-127.
{17}Isay, R. A. (1988). "Homosexuality in Heterosexual and Homosexual Men." Psychiatric Annals.lS.(1). pp.43-46.
{18}Schwartz, M. F. and Masters, W. H. (1984). "The Masters and Johnson Treatment Program for DissatisfiedHomosexualMen."AmericanJournalofPsychiatry.141. pp.173-181.
{19}Ellis, L. et al. (1978). "Sexual Orientation as a Continuous Variable." Archives of Sexual Behavior. 16. pp. 523-529.
{20}McConaghy, N. (1987). "Heterosexuality/Homosexuality. Dichotomy or Continuum?" Archives of Sexual Behavior. 16. pp.411-423.
{21}Billy, J. O. et al. (1993). "The Sexual Behavior of Men in the United States: Family Planning Perspectives." The Journal of the Alan Guttmacher Institute. 25. pp. 52-60.
{22}Isay, R. A. (19911. "The Homosexual Analyst." In Psychoanalytic Study of the Child. pp. 199216 (subsequently referred to as "HA.")
{23}Isay, R. A. (1986). "On the Analytic Therapy of Gay Men." In Stein, T. S. and Cohen, C. J. editors. Contemporary Perspectives on Psychotherapy with Lesbians and Gay Men. New York, Plenum. pp. 139-155 (subsequently referred to as ATOM.)
{24}ATGM pp. 140.
{25}ATGM pp. 144.
{26}ATGM pp. 145.
{27}Glasser, M. (1977). "Homosexuality in Adolescence." British Journal of Medical Psychology. 50. pp. 217-225.
{28}ATGM pp. 145.
{29}ATGM pp. 146.
{30}ATGM pp. 148.
{31}ATGM pp. 149.
{32}Ovesey, L. (1969). Homosexuality and Pseudohomosexuality. New York, Science House.
Updated: 8 February 2008
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